LIFE INSURANCE ADVISORS, INC.

FEE-ONLY INSURANCE CONSULTING

714 E. PROSPECT AVENUE LAKE BLUFF, ILLINOIS 60044
PHONE (847) 482-1605 FAX (815) 377-3631
david@lifeinsuranceadvisorsinc.com
www.lifeinsuranceadvisorsinc.com

Questionnaire for Initial Review

of New Term Life Insurance Policy

Your answers to the questionnaire below will enable Life Insurance Advisors, Inc. to determine
whether you will likely benefit from a more complete review of a life insurance policy proposal. We
need contact information for you and a few details about the insured and the policy.

If some of the information is not known, please provide as much of it as is conveniently available. For
example, the insured will know information about their health and activities that another person
answering this questionnaire, such as an advisor, may not know.

A. Your Contact Information

1. Please indicate whether you are (circle any that apply): the insured, policy owner, premium payor,
client advisor, other (please specify if other).

2. If you are a client advisor, please indicate whether you are (circle any that apply): attorney,
accountant, trustee of an insurance trust owning the policy, independent financial advisor, insurance
agent or broker, other.

3. Your Name: ____________________________________________________________________

First Middle Initial Last

4. Preferred address: ________________________________________________________________

Employer/Firm Name (if applicable)

___________________________________________________________
Number and Street

___________________________________________________________
City State Zip

5. Preferred Phone # __________________________________________________________

6. E-mail Address: ___________________________________________________

Copyright, Life Insurance Advisors, Inc., 2006. All Rights Reserved.

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7. Name, sex, date of birth, and state of residence of proposed insured or insureds if not indicated
above:

8. Proposed insurance company, if any so far. If you have a policy illustration(s) already, please
include it with your questionnaire?

9. Type of term insurance policy proposed, if any, so far (circle one): level premium (and, if so, for
number of years), or increasing annual premium. Please specify annual premium if level premium.

10. Amount of insurance death benefit you are considering purchasing?

11. Amount and duration of replacement income that you would want the term insurance to provide if
insurance is for personal purposes and is intended to generate replacement income for surviving
dependents (for example, $100,000/year in todays dollars for 25 years, and $75,000 thereafter):

12. Do you want the replacement income that would be generated by the term insurance proceeds to
increase with inflation?

13. State any additional or alternative purpose of the proposed term insurance as completely as possible.

14. Please specify the financial circumstances giving rise to the interest in the purchase of life insurance,
including: current earned income, current investment income, net worth, and the amount of liquid
assets that would serve, along with the life insurance, to provide replacement income if the insured
dies prematurely. In the case of insurance funding a business buy-sell agreement, please note the
value of the business interest that the insurance proceeds would be used to acquire, and, in the case
of key man insurance, note the position and responsibilities of the key person to be insured and
describe such persons value to the business:

15. Please rate the importance of the following goals for the insurance policy on a scale from 1 to 5, with
1 indicating great importance and 5 indicating little importance:

a. Minimizing the cost of the insurance as much as possible: 1 2 3 4 5

b. Knowing that the insurance company with which you have your policy
has very strong financial solvency ratings: 1 2 3 4 5

c. Being able to convert the term insurance in the future, without an additional
medical exam, into a high quality permanent insurance policy: 1 2 3 4 5
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d. If c. is an objective, please state the amount or percentage of the term insurance

coverage that you might want to convert to permanent insurance in the future: _________

16. If a particular insurance company and policy has already been proposed, will you:

a. Consider an alternative company or policy that an independent

consultant, who does not sell insurance, might recommend? Yes No

b. If the answer to Question 10(a) is yes, would you consider this alternative
even if the agent or broker making the original proposal cannot offer the alternative
policy because he or she cannot be licensed with the company that issues it? Yes No

17. Please specify any health conditions or hazardous activities of the insurance applicant that might
influence the underwriting of this policy. Please provide details with regard to height, weight, blood
pressure, cholesterol, any heart history, cancer, diabetes, treatment for depression, medications, visits
to physicians within the previous 5 years that may be relevant, etc.

a. Approximate height and weight of the insurance applicant:

Height _______________ Weight ______________

b. Did either of the insurance applicants parents or any siblings experience cardiovascular
disease or cancer prior to age 60?
Yes ______ No _______
Please explain: include age of onset, diagnosis, and age of death (if applicable and known):

c. Does the insurance applicant participate in hazardous activities, such as, but not limited to,
flying private airplanes, mountain climbing, riding motorcycles, scuba diving, etc? Please
provide any relevant details:

18. Is the insurance applicant(s) a smoker of cigarettes, pipes, or cigars or a user of tobacco in any way?
If a cigar smoker, specify approximately how many cigars are smoked in a week, month or year.

19. Please describe the amount and type of any other life insurance you own:

When the questionnaire is completed, either e-mail it to david@lifeinsuranceadvisorsinc.com with the

completed questionnaire attached as a Word document, or fax it to 815-377-3631. If you have a policy
illustration of the policy you are considering, please include it.